Fondulac Rehabilitation And Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in East Peoria, Illinois.
- Location
- 901 Illini Drive, East Peoria, Illinois 61611
- CMS Provider Number
- 145266
- Inspections on file
- 28
- Latest survey
- June 12, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Fondulac Rehabilitation And Health Care Center during CMS and state inspections, most recent first.
A cognitively impaired, nonverbal resident with multiple diagnoses was sexually abused on more than one occasion by another resident. Staff witnessed and reported the incidents, but administration failed to provide guidance, implement safety interventions, or ensure required assessments and notifications were completed. Both residents' care plans lacked appropriate interventions, and the facility did not follow its abuse prevention policy.
A cognitively impaired resident with multiple medical conditions exited the facility unsupervised through an unsecured smoking patio door after staff failed to follow elopement protocols, including conducting a head count when a door alarm sounded. The resident was later found over two miles away in the dark and cold. Additionally, another high-risk resident was not provided with required electronic monitoring or one-on-one supervision, despite care plan directives.
Staff failed to immediately report and investigate an incident where a resident was witnessed sexually abusing another resident on two occasions. Despite being informed, the administrator in training did not notify the state agency, law enforcement, or the resident's representative, and the alleged perpetrator continued to have unsupervised access to other residents, violating the facility's abuse reporting policy.
Two CNAs witnessed a resident sexually assaulting another resident on two occasions, but the facility failed to investigate, implement protective interventions, or report the incident to the state agency. The alleged perpetrator continued to have unsupervised access to all residents, and no increased supervision or safety measures were documented in the medical records.
The facility failed to employ a licensed administrator, resulting in the lack of investigation and reporting of a witnessed sexual abuse incident between two residents. Staff did not receive required annual in-service trainings, and multiple staff members reported that the acting administrator attempted to cover up the abuse, altered witness statements, and did not notify authorities or provide direction to protect residents.
The facility did not provide required annual QAPI in-service training to all staff, as confirmed by the DON and review of facility records. This deficiency had the potential to affect all 79 residents currently residing in the facility.
The facility did not provide required annual infection control and prevention training to its staff, as confirmed by the DON, despite having 79 residents in care and a scheduled training on the in-servicing calendar.
The facility did not provide annual Compliance and Ethics in-service training to any staff, as confirmed by the DON, despite the training being scheduled. This affected all staff while 79 residents were present in the facility.
All staff did not receive the required annual behavioral health in-service training, as confirmed by the DON and documented in facility records. This lapse could impact all 79 residents in the facility.
A resident with multiple health conditions sustained a deep leg laceration requiring hospital treatment after a CNA failed to ensure the resident's legs were clear before repositioning their wheelchair. The facility's policy on skin condition monitoring was not followed, and the CNA was terminated for poor performance.
A resident with Type Two Diabetes Mellitus and Diabetic Chronic Kidney Disease did not receive physician-ordered insulin, leading to emotional distress and abnormal lab values indicating hyperglycemia. The facility's records showed numerous instances of missed insulin administrations and blood glucose checks. The resident's Hemoglobin A1C was significantly higher than the physician's target, and the physician noted that the lack of insulin and monitoring could have contributed to this.
The facility failed to serve foods as written on the menu, affecting all 63 residents. The menu listed specific items, but residents received different foods. The Dietary Manager was unaware of the reasons for substitutions and attributed it to a new cook. Residents complained about frequent menu discrepancies, and the substitution book lacked proper documentation and Dietitian sign-off.
The facility failed to maintain proper food safety and sanitation practices, affecting all 63 residents. Unlabeled and undated food items were found in the resident refrigerator, and a cook improperly mixed a chlorine solution, resulting in a poisonous concentration. Additionally, unsanitary conditions were observed in the kitchen, and pre-cooked chicken was placed on the steam table hours before serving. The Dietary Manager and DON confirmed these issues, indicating a lack of adherence to facility policies.
The facility did not have an RN on duty for eight consecutive hours on four days in July 2024, as confirmed by the Assistant DON. This staffing gap was contrary to the facility's assessment plan to ensure sufficient staffing for its 63 residents.
The facility failed to perform proper hand hygiene during medication administration and did not implement Enhanced Barrier Precautions (EBP) to prevent the spread of MDROs. An LPN was observed handling medications and administering insulin without gloves or hand hygiene. Additionally, staff were not following EBP protocols for residents with indwelling devices or open wounds, and there was a lack of awareness and implementation of EBP throughout the facility.
The facility failed to notify residents, their representatives, and the Ombudsman of hospital transfers. Several residents were transferred multiple times without written notices, and the Social Services Director and Administrator confirmed the lack of notifications. This deficiency could impact all 47 residents.
The facility failed to provide the required bed hold policy notice to four residents upon their transfer to a hospital, as mandated by their policy. This deficiency was confirmed by the Social Services Director and the facility administrator, who acknowledged the oversight.
The facility failed to develop comprehensive care plans for four residents regarding their use of anticoagulants and psychotropic medications, as well as target behaviors for one resident. The Care Plan Coordinator and Assistant Director of Nursing confirmed the absence of these care plans, indicating a failure to meet the facility's policy of developing person-centered care plans.
The facility failed to perform the required nurse shift-to-shift controlled substance reconciliation for 19 residents receiving controlled substances. The facility's policy requires Schedule II drugs to be counted and reconciled by the incoming and outgoing nurses, with records retained for at least one year. However, documentation was missing for specific dates, as confirmed by an LPN and the DON, indicating a lapse in policy adherence.
A resident reported that an LPN deliberately delayed medication administration, causing distress. Despite the resident's complaints to the administration, the facility failed to report the alleged mental abuse to the state agency, violating their abuse prevention policy.
A resident alleged mental abuse by an LPN, claiming the nurse withheld medications and laughed about it. Despite the facility's policy to remove accused employees from resident contact, the LPN was not removed, and no formal abuse investigation was conducted. The resident, who was cognitively intact, expressed distrust and refused medications from the LPN, leading to the ADON administering them instead.
The facility failed to complete PASARR screenings for three residents with mental disorders or intellectual disabilities. One resident with Schizophrenia and Psychosis had no PASARR Level I documentation. Another resident, admitted with Schizophrenia, did not receive a required follow-up PASARR after 60 days. A third resident with Bipolar Disorder lacked any PASARR documentation. The ADON confirmed these deficiencies.
The facility failed to perform physician-ordered daily skin checks and scheduled pressure ulcer treatments for three residents, and did not develop a care plan for one resident's pressure ulcers. A resident with spastic cerebral palsy and other conditions missed 10 out of 17 skin checks, while another with multiple health issues missed 3 out of 7. A third resident with pressure injuries had missed treatments and lacked a care plan, with staff confirming documentation gaps.
An LPN failed to perform hand hygiene between glove changes while providing suprapubic catheter care to a resident with Neurogenic Bladder and Obstructive Uropathy. This breach in infection control practices occurred despite the resident's history of urinary tract infections and a care plan aimed at preventing such infections.
A facility failed to ensure a licensed pharmacist conducted monthly drug regimen reviews for a resident over six months. Despite the facility's policy requiring monthly meetings with a consultant pharmacist for potential medication reductions, the resident's medical record showed no reviews from March to August. The DON confirmed only one review was completed in February.
The facility failed to document diagnoses and target behaviors for the use of antipsychotic medications for three residents. One resident was on Seroquel without a documented diagnosis or behaviors justifying its use. Another resident, despite having schizophrenia, had no documented target behaviors or dose reduction attempts for Clozaril. A third resident was on multiple psychotropic medications without recent dose reductions, despite recommendations. Observations showed minimal adverse behaviors, and staff were unaware of justifications for the medications.
A resident with multiple serious conditions did not receive physician-ordered lab tests, including a CMP and CBC, due to staff oversight. The DON confirmed the lapse in ordering the necessary tests.
Failure to Protect Resident from Sexual Abuse and Inadequate Response
Penalty
Summary
The facility failed to protect a cognitively impaired resident from repeated sexual abuse by another resident who was cognitively intact. On two separate occasions during breakfast, staff observed the perpetrating resident sitting next to the victim, with their hand between the victim's legs, touching the victim's vagina. Despite staff intervening and verbally instructing the perpetrator to stop, the inappropriate contact recurred within a short period. The staff reported the incident to the Administrator in Training, who did not come to the facility, did not provide guidance, and did not implement safety interventions to prevent further abuse. The victim was severely cognitively impaired, nonverbal, and had diagnoses including cerebral palsy, intellectual disabilities, anxiety, and depression. The victim's care plan did not include interventions to prevent sexual abuse, and there was no documentation or assessment of the victim following the abuse. Additionally, a trauma care assessment was not completed after the incident, and the victim's guardian was not notified of the allegation. The perpetrator's care plan also lacked interventions addressing sexual behaviors, and there was no documentation of the abuse allegation in the perpetrator's medical record. The facility's abuse prevention policy required immediate steps to prevent further abuse, assessment of the resident, notification of the physician and responsible party, and completion of a trauma-informed care assessment. These steps were not followed after the incident, as the staff did not receive direction from administration, and the required assessments and notifications were not completed. This failure resulted in an Immediate Jeopardy situation due to the lack of protection and appropriate response to resident-to-resident sexual abuse.
Failure to Prevent Elopement and Provide Adequate Supervision for At-Risk Residents
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents, specifically related to elopement risk. A cognitively impaired resident with multiple diagnoses, including chronic obstructive pulmonary disease, hemiplegia, diabetes, and depression, was assessed as a moderate risk for elopement and had a history of exit-seeking behavior. Despite these known risks, the resident's care plan did not include interventions to address elopement until after the resident had already left the facility without staff knowledge or supervision. The resident was able to exit through a smoking patio door, which was not kept secure, and the door alarm was dismissed by staff without a resident head count or further investigation, as required by facility policy. The incident occurred when the resident exited the facility during the night and was later found 2.2 miles away, standing on a concrete median by a stop light in the dark, expressing that he was cold. Staff interviews revealed that the nurse on duty heard the door alarm but assumed it was triggered by the wind and did not follow procedures to account for all residents, particularly those at risk for elopement. The resident was not discovered missing until several hours later when another staff member found him outside the facility. The resident required a walker, had impaired cognition, and was not safe to be outside unsupervised, especially at night and in cold weather. Additionally, another resident identified as high risk for elopement was observed without the required electronic sensor device or one-on-one supervision, despite care plan directives. Staff confirmed that this resident had not been provided with the necessary monitoring devices or supervision. The facility's elopement policy required immediate response to door alarms, investigation of the cause, and accounting for all at-risk residents, but these procedures were not followed, contributing to the deficiencies identified.
Failure to Report and Respond to Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to follow its abuse policy and procedures by not immediately reporting and investigating an incident of resident-to-resident sexual abuse. Two certified nursing assistants witnessed a resident placing their hand up another resident's shorts and touching the resident's vagina on two separate occasions. The first incident was not reported to the administrator, and only after the second incident did the nursing assistants inform the LPN, who then contacted the administrator in training. Despite these reports, the administrator in training did not notify the state agency, local law enforcement, or the resident's representative as required by the facility's policy. During the period following the incident, the resident who committed the abuse continued to have unsupervised access to all other residents in the facility. The facility's policy mandates immediate reporting of all abuse allegations to the administrator, state agency, and law enforcement, with a summarized investigation to be completed within five business days. However, the administrator in training confirmed that no report was made to the required authorities regarding the witnessed sexual abuse, resulting in a failure to protect residents and comply with mandated reporting requirements.
Failure to Investigate and Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to implement its abuse policy and procedure in response to an allegation of resident-to-resident sexual abuse. Two certified nursing assistants witnessed one resident placing their hand up another resident's shorts and touching the resident's vagina on two occasions. Despite this, the administrator in training confirmed that no investigation was conducted, and no report was submitted to the state agency. The electronic medical records for both residents did not include any interventions or increased supervision to protect the affected resident or others from further abuse. Additionally, the alleged perpetrator continued to have unsupervised access to all residents in the facility following the incident. Staff interviews revealed that the administrator was made aware of the allegations but did not provide any immediate safety interventions and delayed the start of the investigation. Observations showed the alleged perpetrator moving freely throughout the facility and in proximity to the victim after the incident. The facility's abuse policy requires immediate reporting, thorough investigation, protective measures, and timely submission of a final report to the state agency, none of which were followed in this case.
Unlicensed Administrator and Failure to Investigate and Report Abuse
Penalty
Summary
The facility failed to employ a licensed administrator, as required, to ensure the protection of all residents from abuse, proper investigation and reporting of abuse allegations, and the provision of mandatory staff training. The individual acting as Administrator was hired without evidence of a bachelor's degree or a temporary or permanent administrator's license. This individual admitted to not having the required qualifications and did not receive a temporary license at any time during their tenure. The facility's records also showed that staff did not receive required annual in-service trainings, including the 12-hour CNA training, QAPI, behavioral health, infection control, and compliance and ethics program trainings. Multiple staff members reported that the acting administrator failed to investigate and report a witnessed incident of sexual abuse between two residents. Staff described the administrator as attempting to minimize or cover up the incident, altering witness statements, and failing to notify the state agency, police, or resident representatives. Staff also reported a lack of direction from the administrator regarding the separation of the involved residents. The Director of Nursing confirmed the absence of required staff trainings, and several staff members expressed concerns about the administrator's truthfulness and intimidating behavior.
Failure to Provide Annual QAPI Training to All Staff
Penalty
Summary
The facility failed to provide mandatory annual in-service training on the Quality Assurance and Performance Improvement (QAPI) program to all staff, as required by its own policy. Record review showed that the annual in-servicing calendar specified QAPI training for all staff in March, but verification by the Director of Nursing confirmed that no staff had received this training for the current year. At the time of the survey, 79 residents were documented as residing in the facility, and this lack of training had the potential to affect all of them. The deficiency was identified through both record review and staff interview.
Failure to Provide Annual Infection Control Training to All Staff
Penalty
Summary
The facility failed to ensure that all staff received annual in-service training on Infection Control and Prevention as required by its infection prevention and control program. Record review showed that the facility's annual in-servicing calendar scheduled infection prevention and control training for all staff in April. However, as verified by the Director of Nursing, no staff received this training. At the time of the survey, 79 residents were residing in the facility.
Annual Compliance and Ethics Training Not Provided to Staff
Penalty
Summary
The facility failed to ensure that all staff received annual Compliance and Ethics in-service training. Record review showed that the in-service calendar scheduled this training for all staff in April, but verification by the Director of Nursing confirmed that no staff had received the required training. At the time of the survey, 79 residents were residing in the facility.
Failure to Provide Annual Behavioral Health Training to All Staff
Penalty
Summary
The facility failed to ensure that all staff received annual in-service training on behavioral health, as required by facility policy and assessment. Record review showed that the in-service calendar scheduled behavioral health training for all staff in January and behavioral management training in October. However, as verified by the Director of Nursing, no staff received the required annual behavioral health training. This deficiency has the potential to affect all 79 residents currently residing in the facility.
Resident Injury Due to Inadequate Supervision During Repositioning
Penalty
Summary
The facility failed to ensure the safety of a resident during repositioning, resulting in a significant injury. The resident, who had multiple diagnoses including Chronic Obstructive Pulmonary Disease, Emphysema, and Osteoporosis, sustained a deep leg laceration requiring hospital treatment. The incident occurred when a Certified Nurses Aide (CNA) attempted to recline the resident's wheelchair, causing the resident's leg to become caught on the edge of the bed, leading to a 10.5 cm laceration. The facility's Skin Condition Monitoring policy requires proper monitoring and documentation of skin abnormalities, but there was no documentation of prevention techniques in use for the resident. The CNA involved in the incident did not ensure the resident's legs were clear of obstacles before moving the wheelchair, which directly led to the injury. The CNA was later terminated for poor work performance, including sleeping on the job. Interviews with facility staff revealed that the CNA failed to check the resident's leg position before moving the wheelchair, which was a critical oversight. The Assistant Director of Nursing confirmed that the CNA should have been more vigilant in ensuring the resident's safety. The facility did not have a Quality Assurance form for the newly acquired skin condition, indicating a lapse in following their own procedures for documenting and addressing skin injuries.
Failure to Administer Insulin as Ordered
Penalty
Summary
The facility failed to administer physician-ordered insulin to a resident diagnosed with Type Two Diabetes Mellitus with Diabetic Chronic Kidney Disease. This failure was identified through interviews and record reviews, revealing that the resident experienced emotional distress due to not receiving insulin as ordered. The resident expressed fear that the facility's staff might harm him by not administering his insulin correctly. This situation resulted in multiple abnormal laboratory values indicating hyperglycemia. The facility's policies on Adverse Drug Reactions and Medication Discrepancy, as well as Medication Administration, were not adhered to. The resident's Medication Administration Records from May to August showed numerous instances where blood glucose level checks and insulin administrations were not documented. Specifically, there were significant omissions in administering Tresiba, Trulicity, and Lispro insulin, as well as in recording blood glucose levels. These omissions were confirmed by the Assistant Director of Nursing, who stated that blank entries could be interpreted as tasks not completed. The resident's laboratory results further highlighted the issue, with fasting glucose levels consistently high and a Hemoglobin A1C level of 9.3, which was above the physician's target of 8 or below. The physician had ordered a Hemoglobin A1C test based on earlier high glucose levels, but it was not conducted until months later. The physician acknowledged that the lack of insulin administration and routine blood sugar monitoring could have contributed to the elevated Hemoglobin A1C levels.
Failure to Serve Menu Items as Planned
Penalty
Summary
The facility failed to serve foods as written on the menu, which has the potential to affect all 63 residents living in the facility. On the specified date, the menu listed Oven Fried Chicken Breast, Mashed Potatoes, Chicken Gravy, Mixed Vegetables, Roll/Margarine, and Pie, but residents were served Plain Baked Chicken, Mashed Potatoes, Carrots, Bread, and Strawberry Pie. The Dietary Manager, V5, was unaware of why the substitutions occurred and mentioned that the frozen mixed vegetables did not arrive, although canned mixed vegetables were available. Additionally, there were frozen rolls in the freezer that could have been used. The Dietary Manager attributed the issue to a new cook who was unfamiliar with the procedures. During a group interview with the Resident Council, several residents complained that the menu often listed items that were not served, and they were given various reasons for the discrepancies, such as delivery issues or the cook's preferences. The facility's substitution book, which is supposed to document all menu changes and be signed off by a Registered Dietitian, had few entries, and the Dietitian had not signed off on the substitutions. An example of an improper substitution was Banana Pudding instead of a serving of fruit, which was not documented correctly in the substitution book.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure proper food safety and sanitation practices, which could potentially affect all 63 residents. Observations revealed that the floor refrigerator designated for resident use emitted a strong sour odor and contained various unlabeled and undated food items, including a cheese package, take-out containers with spoiled chicken, dried spaghetti, and a sandwich dated from the previous month. Additionally, a murky bottle of water with brown lemon slices, a bag of mixed fruits, and several unidentified items in the freezer were found without proper labeling or dating. The Dietary Manager and Director of Nursing confirmed these items should have been discarded and labeled appropriately. In the kitchen, the facility did not adhere to proper sanitation solution preparation. A cook was observed mixing a chlorine solution using a bottle cap instead of a measuring spoon, resulting in a concentration over 200 parts per million, which is considered poisonous. Despite attempts to correct the solution, the concentration remained above the required level. The cook, who had limited English proficiency, was unable to confirm if he routinely checked the chlorine levels or knew the correct concentration. Additionally, food items in the reach-in and walk-in refrigerators were found without labels or dates, including thickened liquids, cheese slices, and sour cream, which the Dietary Manager acknowledged should have been labeled and discarded. Further inspection of the kitchen revealed unsanitary conditions, such as a layer of dust on the interior baffles and a black, greasy dust on the fans above the food preparation area. The steam table contained pre-cooked chicken placed hours before serving, which the cook admitted to doing routinely. The Dietary Manager stated that the chicken only needed to be heated before serving. These findings indicate a lack of adherence to the facility's policies on food storage, sanitation, and preparation, as well as inadequate monitoring and communication among staff.
RN Staffing Deficiency in July 2024
Penalty
Summary
The facility failed to maintain the required staffing levels by not having a Registered Nurse (RN) on duty for eight consecutive hours on four specific days in July 2024. This deficiency was identified through interviews and record reviews, which revealed gaps in the nursing schedule on the weekends of July 6th, 7th, 20th, and 21st. The Assistant Director of Nursing confirmed these gaps in coverage. The facility's assessment plan, dated August 12, 2024, was intended to ensure sufficient staffing to meet resident needs, but the July schedule did not reflect this plan. At the time of the report, 63 residents were residing in the facility, as documented in the facility's Long-Term Care Facility Application for Medicare and Medicaid Form CMS 671, signed by the Administrator on August 18, 2024.
Inadequate Infection Control and EBP Implementation
Penalty
Summary
The facility failed to adhere to proper hand hygiene protocols during medication administration for two residents. An LPN was observed preparing and administering medications to a resident without wearing gloves and without performing hand hygiene. The LPN handled various medications directly with bare hands and administered insulin injections without gloves, subsequently touching another resident's medication without sanitizing hands in between. This practice was in direct violation of the facility's policy on standard precautions and medication administration, which mandates the use of gloves and hand hygiene to prevent the spread of microorganisms. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) to prevent the spread of multi-drug resistant organisms (MDROs) among residents. The facility's policy requires the use of gowns and gloves during high-contact care activities for residents with open wounds, indwelling medical devices, or those colonized with MDROs. However, observations revealed that staff were not following these precautions. For instance, a resident with an indwelling urinary catheter did not have EBP signage or personal protective equipment (PPE) available in their room. Another resident with a pressure ulcer did not have appropriate EBP measures in place during care. Interviews with staff indicated a lack of awareness and implementation of EBP throughout the facility. Some staff members were unfamiliar with the concept of Enhanced Barrier Precautions, and there was a noticeable absence of necessary PPE and signage in rooms where it was required. The Assistant Director of Nursing acknowledged the oversight and confirmed that the facility's infection control procedures were not being fully implemented, despite being aware of the requirements.
Failure to Notify Residents and Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to provide timely notification to residents, their representatives, and the facility Ombudsman regarding transfers to the hospital. Specifically, the facility did not provide written notices of transfer to residents R25, R35, R45, and R70, nor did it notify the Ombudsman of these transfers. This deficiency was confirmed through interviews and record reviews, revealing that the Social Services Director and the Administrator acknowledged the lack of notifications. Resident R25 was transferred to a local hospital on two occasions, and R35 was transferred three times, with no evidence of notification in their records. Similarly, R45 was transferred four times without written notice. Resident R70, who had a history of cardiac arrest and respiratory failure, was transferred to the hospital without a written notice or Ombudsman notification. These failures have the potential to affect all 47 residents in the facility.
Failure to Provide Bed Hold Policy Notice
Penalty
Summary
The facility failed to provide a copy of the bed hold policy to residents or their representatives upon transfer to a hospital or during therapeutic leave, as required by their own policy. This deficiency was identified for four residents, R25, R35, R45, and R70, out of a sample of 47. The facility's Bed Hold Guarantee Policy, revised on 8/1/17, mandates that the resident, their family, or legal representative be given the 'Notice of Bed Hold Policy' at the time of discharge or therapeutic leave, or within 24 hours thereafter. However, the medical records for these residents did not contain documentation of such notice being provided. Specifically, R25 was hospitalized on two occasions, and R35 on three occasions, without receiving the required notice. The Social Services Director confirmed that neither resident nor their representatives were provided with the bed hold policy or a written notice of transfer. Similarly, R45 was transferred to the hospital on four separate occasions without documentation of a bed hold notice. R70, who was transferred to the hospital after experiencing shortness of breath, also did not receive the bed hold policy notice. The facility administrator acknowledged that the policy was not provided to R70 upon transfer.
Failure to Develop Comprehensive Care Plans for Medications and Behaviors
Penalty
Summary
The facility failed to develop comprehensive care plans for four residents regarding their use of anticoagulants and psychotropic medications. Specifically, the care plans for these residents did not address the use of medications such as Eliquis, Aripiprazole, Buspar, Klonopin, Luvox, Remeron, and Sertraline. This oversight was confirmed by the Care Plan Coordinator, who acknowledged the absence of care plans for these medications. Additionally, the facility did not address target behaviors exhibited by one resident, who displayed behaviors such as hoarding, agitation, and self-isolation. The Assistant Director of Nursing confirmed that these behaviors were not documented in the resident's care plan, despite being aware of them. The lack of comprehensive care plans for these residents indicates a failure to meet the facility's policy of assessing and reassessing residents to develop person-centered care plans.
Failure in Controlled Substance Reconciliation
Penalty
Summary
The facility failed to perform the required nurse shift-to-shift controlled substance reconciliation for 19 residents who were receiving controlled substances. The facility's policy mandates that all Schedule II drugs must be counted and reconciled by the nurse coming on duty with the nurse going off duty, and these records should be retained for at least one year. However, a review of the narcotic Shift Change Accountability Record Sheet for Controlled Substances for August 2024 revealed missing nursing documentation for the required reconciliation on specific dates. This was confirmed by a Licensed Practical Nurse and the Director of Nurses, indicating a lapse in adherence to the facility's policy for controlled substance management.
Failure to Report Alleged Mental Abuse
Penalty
Summary
The facility failed to report an allegation of staff-to-resident mental abuse to the state agency, as required by their Abuse Prevention Program policy. The policy mandates that all alleged violations involving mistreatment, neglect, or abuse must be reported immediately to the administrator and other officials in accordance with state law. In this case, a resident, who was cognitively intact, reported that a Licensed Practical Nurse (LPN) would deliberately delay administering medications and laugh about it, causing distress to the resident. The resident communicated these concerns to the Administrator in Training, the Director of Nursing, and the Assistant Director of Nursing, but no report was made to the state agency. The Administrator in Training, who is also the Abuse Coordinator, confirmed that no abuse report was submitted to the state agency despite being informed of the resident's conflicts with the LPN. The Assistant Director of Nursing acknowledged the resident's complaints and stated that there was a personality conflict between the resident and the LPN. The facility's response was to avoid conflict by not assigning the LPN to the resident's hall until the resident was discharged. However, the failure to report the allegation to the state agency constitutes a deficiency in adhering to the facility's abuse reporting policy.
Failure to Remove Accused Employee and Investigate Abuse Allegation
Penalty
Summary
The facility failed to immediately remove an employee accused of mental abuse from resident care and did not complete an abuse investigation for a resident who alleged mistreatment. The facility's policy mandates that employees accused of abuse be immediately removed from resident contact until an investigation is completed. However, in this case, the accused employee, a Licensed Practical Nurse (LPN), was not removed from resident contact after a resident, who was cognitively intact, reported that the LPN was withholding medications and laughing about it, causing distress to the resident. The resident had previously voiced allegations of mistreatment by caregivers, and the care plan required such allegations to be investigated per facility protocol. Despite the resident's complaints and the involvement of the Assistant Director of Nursing (ADON) in addressing the situation, the Administrator in Training, who was also the Abuse Coordinator, did not perceive the situation as abuse and did not conduct a formal investigation or remove the LPN from resident contact. The resident expressed distrust towards the LPN and refused to take medications from her, leading to the ADON administering the medications instead.
Failure to Complete PASARR Screenings for Residents with Mental Disorders
Penalty
Summary
The facility failed to ensure that a PASARR (Preadmission Screening and Resident Review) was completed for three residents with mental disorders or intellectual disabilities. Resident 1, who has diagnoses of Schizophrenia and Psychosis, did not have any documentation of a PASARR Level I screening in their medical record. The Assistant Director of Nursing (ADON) confirmed that there was no record of such a screening ever being completed for this resident. Resident 58, admitted with a diagnosis of Schizophrenia, had a PASARR Level I screening indicating the need for further assessment after 60 days. However, the facility did not conduct an additional PASARR screening once the resident's stay exceeded this period. Similarly, Resident 44, diagnosed with Bipolar Disorder and other psychiatric conditions, had no documentation of a PASARR screening in their medical record. The ADON acknowledged the absence of a PASARR for this resident and mentioned that a request for a screen had been made.
Failure to Perform Skin Checks and Document Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that physician-ordered daily skin checks and scheduled pressure ulcer treatments were completed for three residents, and a pressure ulcer care plan was not developed for one resident. The facility's policies on decubitus care, comprehensive care planning, and pressure sore prevention were not adhered to, leading to deficiencies in care. The Director of Nurses verified missing documentation for daily skin checks, indicating non-compliance with physician orders. One resident with spastic cerebral palsy, malnutrition, epilepsy, and scoliosis had a high risk for pressure ulcers, as indicated by a Braden Scale score of 13. However, 10 out of 17 physician-ordered daily skin checks were not performed. Another resident with a history of bilateral knee amputation, chronic kidney disease, type 1 diabetes mellitus, chronic diastolic heart failure, and depression with anxiety was at moderate risk for pressure ulcers, with a Braden Scale score of 17. For this resident, 3 out of 7 daily skin checks were not completed. A third resident, who was pleasantly confused and had an active left foot lateral pressure injury and a stage three right hip pressure injury, did not have a care plan for pressure ulcers. The resident's treatment administration record showed missed scheduled skin checks and wound treatments. The Licensed Practical Nurse confirmed gaps in documentation and stated that the responsibility for daily treatments lay with the floor staff. The Minimum Data Set/Care Plan coordinator acknowledged the absence of pressure ulcer documentation in the resident's care plan and MDS assessment.
Failure in Hand Hygiene During Catheter Care
Penalty
Summary
The facility failed to adhere to its Standard Precautions policy during the care of a resident with a suprapubic catheter. Specifically, a Licensed Practical Nurse (LPN) did not perform hand hygiene between glove changes while providing catheter care to a resident diagnosed with Neurogenic Bladder and Obstructive Uropathy. The facility's policy mandates handwashing after touching blood, body fluids, secretions, excretions, and contaminated items, and immediately after glove removal to prevent cross-contamination. However, the LPN removed a gauze dressing saturated with bloody drainage from the resident's catheter site, changed gloves without washing hands, and continued with the catheter care. The resident's care plan aimed to prevent urinary infections, yet the LPN acknowledged the oversight in hand hygiene, which is crucial in preventing infections. The resident had a history of urinary tract infections, and a recent urinalysis showed abnormal results with a significant growth of Providencia Stuartii, indicating a potential infection. This incident highlights a breach in infection control practices, which could contribute to the resident's ongoing urinary health issues.
Failure to Conduct Monthly Drug Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist conducted a monthly drug regimen review for a resident over a period of six consecutive months. This deficiency was identified for one of the five residents reviewed for unnecessary medications in a sample of 47. According to the facility's Psychotropic Medication Policy, nursing administration is required to meet with the consultant pharmacist monthly to discuss residents who may need or are due for a medication reduction. However, the medical record of the resident in question, as of August 20, 2024, showed no documentation of medication regimen reviews by a licensed pharmacist for the months of March through August 2024. The Director of Nursing confirmed that only one medication regimen review was completed for this resident in February 2024, indicating a lapse in adherence to the facility's policy.
Failure to Document Justification and Attempt Gradual Dose Reduction for Psychotropic Medications
Penalty
Summary
The facility failed to document a diagnosis and target behaviors to justify the use of antipsychotic medication for three residents, R7, R49, and R60. For R60, there was no documented diagnosis for the use of Seroquel, and the care plan did not reflect the use of antipsychotic medication. Observations and interviews indicated that R60 did not exhibit behaviors warranting such medication, and the Assistant Director of Nursing (ADON) was unaware of any behaviors or diagnosis justifying its use. For R49, although diagnosed with schizophrenia and other mood disorders, there was no documentation of target behaviors or consistent adverse behaviors in the behavior tracking records. The care plan lacked mention of any behavioral interventions, and the ADON confirmed the absence of documented adverse behaviors. Despite being on Clozaril since June 2022, no gradual dose reduction was attempted, contrary to recommendations. R7 was prescribed multiple psychotropic medications, including Aripiprazole, without a recent gradual dose reduction, despite pharmacy recommendations. The behavior tracking records showed minimal occurrences of behaviors, and observations noted R7 as calm and pleasant. The Director of Nursing acknowledged the overdue status of dose reductions and the lack of documented physician responses to pharmacy recommendations.
Failure to Obtain Physician-Ordered Lab Tests
Penalty
Summary
The facility failed to obtain physician-ordered laboratory tests for a resident, identified as R67, who was admitted with several serious medical conditions, including Acute Hypoxic Respiratory Failure, Diabetic Ketoacidosis, Acute Kidney Injury, Diabetes Mellitus, Dizziness, and Weakness. The physician's orders, dated shortly after admission, required a Complete Metabolic Profile (CMP) and a Complete Blood Count (CBC) to be conducted. However, a review of the resident's medical record a month later revealed that these lab tests had not been performed. The Director of Nurses confirmed the oversight, acknowledging that the staff missed ordering the necessary lab tests for the resident.
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A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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